Provider Demographics
NPI:1003898339
Name:FAHERTY, JAMES C (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:FAHERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 E 19TH ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3388
Mailing Address - Country:US
Mailing Address - Phone:541-296-5657
Mailing Address - Fax:
Practice Address - Street 1:1810 E 19TH ST
Practice Address - Street 2:SUITE 209
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3388
Practice Address - Country:US
Practice Address - Phone:541-296-5657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18414207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR070875Medicaid
ORG25693Medicare UPIN
OR016WFBCFBMedicare ID - Type Unspecified